Lipco Input Form

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online form, please click here for assistance

Your personal details:

Title (Mr, Mrs, Miss, Dr, Prof, etc):

Surname:

First names:

ID Number:

Postal Address:

Postal Code:

Please note: at least one contact number is required!
Use this number in all three fields if no other contact numbers

Telephone No: Home
(include area code)

Telephone No: Work
(include area code)

Cellphone No:

E-mail address:

Employer:

Marital Status: (Married, Single, Divorced, Widow/Widower, Co-habitating):

Your spouse's details:

Surname:

First Names:

Date of birth (dd/mm/YYYY):

Your children's details:

Please enter the details of your children (if applicable) in the fields below. 4 Eldest dependant children (unmarried & unemployed) under the age of 21 years.

Child 1

Surname:

First Names:

Child 3

Surname:

First Names:

Child 2

Surname:

First Names:

Child 4

Surname:

First Names:

Your Extended Family details:

Member 1

Surname:

First Names:

Contact Number

Relation (ie Mother)

Member 3

Surname:

First Names:

Contact Number

Relation (ie Mother)

Member 2

Surname:

First Names:

Contact Number

Relation (ie Mother)

Member 4

Surname:

First Names:

Contact Number

Relation (ie Mother)

Packages

Benefit Table:

Please tick the appropriate premium applicable to you

Membership	Membership Fee p.m.	Basic Benefit Limit p.a.	Mediation Benefit Limit p.a.	Litigation Benefit Limit p.a.	Selection
Platinum	R140.00	unlimited	unlimited	R150 000.00	YES
Gold	R95.00	unlimited	unlimited	R100 000.00	YES
Diamond	R53.00	unlimited	unlimited	R 60 000.00	YES

Add on to your Diamond or Gold membership plan: Extended Family for only R33.00 p.m. Add on to your Platinum membership plan: Extended Family for only R50.00 p.m.					YES

Please NOTE: First month’s premium will include an administration fee equal to one month’s premium

Submit

Click on the submit button to send your form to us, or alternatively, click on reset to clear all information.